In honor of National Breastfeeding Month and World Breastfeeding Week, I (Brianne) am writing an article on the new mastitis protocol. I breastfed 5 babies and got mastitis at least twice with every baby. On baby #5, I chose to wean at 11 months after a particularly bad bout of mastitis (and a lifetime total of 10+ mastitis occurrences.) I was just over it! I wish this new protocol had been out at the time, as I have had the opportunity to use these new recommendations on many moms with backed up areas of the breast and even outright mastitis, and in my experience, they work much better than the old recommendations I was using during my mastitis occurrences.
The Academy of Breastfeeding Medicine recently published a new protocol for treating mastitis in lactating women (ABM protocol #36). Most of the recommendations are new and differ significantly from the previous recommendations. The internet being what it is, the out of date recommendations will live on the internet forever. I have seen numerous breastfeeding moms recently who first search online before calling for lactation help with backed up areas of the breast and mastiti
s who were using old guidelines and who subsequently saw quick improvement in their symptoms after switching to the new guidelines. I will outline below the new recommendations and reasoning for them. Some might argue that the old recommendations worked just fine for them and even some lactation professionals have taken issue with some of the new guidelines. I can say that I have had the opportunity to use the new guidelines numerous times with numerous different breastfeeding moms and they have worked beautifully to treat clogged ducts before progressing to mastitis, and even to help take care of symptoms of mastitis before a fever set in and antibiotics were indicated. Read on for the details!
I will list the new recommendations below and elaborate in the following post.
Use only ice, NO HEAT. If possible, use ice every hour on the hour for 15 minutes at a time to the inflamed/painful/reddened area.
Do not overuse the affected side. Do not start on the affected side at every feeding. Start on the unaffected side and proceed to the affected side after feeding on the unaffected side.
Feed on demand and do not try to empty the breast.
Wear a supportive bra to avoid dependent lymphedema (extra swelling in the breast from gravity pulling the breasts downward and away from the chest wall.)
No tight bras or underwire bras, NO sports bras. No compression bras.
Avoid deep or aggressive breast/tissue massage (don’t touch the breast with more force than you would pet a cat.) Practice lymphatic massage to encourage drainage of the breast.
Avoid nipple shields and breast pumps if possible.
No saline soaks, no haakaa Epsom salt soaks, avoid topical products if possible (lanolin, nipple creams).
Check with your medical provider about taking Ibuprofen for pain and inflammation (Ibuprofen has an anti-inflammatory effect) up to 800 mg every 8 hours and Tylenol for pain relief up to 1000 mg every 8 hours. (I am not a physician and cannot prescribe or recommend medications, please consult your medical provider to see if these medications are acceptable in your specific situation.)
Take Sunflower or Soy Lethicin 5-10 mg daily and a good quality probiotic. (I am not a physician, please consult your medical provider to see if these supplements are acceptable in your specific situation.)
If you’re the type of person who cares about the “why” of things, keep reading!
OK let’s talk about ice. Ice decreases inflammation by constricting blood vessels and decreasing blood flow to an area. When you have the inflammation associated with a backed up area of the breast or mastitis, you have swelling inside AND outside the milk ducts. Inside the duct can be narrowed and the duct swells from this narrowing (and often bacterial imbalance) and also swells from infection if full-on mastitis is also present, but you also develop inflammation in the tissue between and around the ducts. Ice will treat the inflammation in both places. While heat can provide relief for some people, the general overriding recommendation is to use ice only.
Do not overuse the affected side. The old recommendation was to start on the affected side at every feeding. The reasoning was to give the most vigorous stimulation (when the nursling is his or her hungriest) to the side with the “plug” to hopefully “unplug” it. Now we know that when you start on the same side at every feeding, it will increase the breast milk supply on that side. When that side has inflammation and a potential backup, this is a problem, as it will only worsen the existing issues. In addition, with advanced imaging techniques, researchers have been able to see that ducts in the breast look more like a tumbleweed than a perfect spider web. Ducts do not necessarily run straight and make predictable turns/pathways, making increased stimulation to “unplug” an area unlikely. Starting on the unaffected side at every feeding will increase the supply on the unaffected side, which is no problem at all. It also gives some rest to and makes up for a temporary decrease on the affected side. Still nurse on the affected side, just use that side second until you have some relief.
Feed on demand and do not try to empty the breast. The way supply works in breastmilk-making is a cool thing! When milk ducts are emptied, the message is sent to the brain to “make more milk, plus a little extra!.” When some breast milk is left in the breast, the message is sent a little less, and if a lot of milk is left in the breast, the “make less milk” message is sent to the brain. When the breast is inflamed and infected, our goal is not to empty the breast, but to back supply down a bit (on the affected side) to aid in healing. So still feed baby, but do not aim to empty the breasts beyond the milk that is required to nourish the baby.
Wear a supportive bra to avoid dependent lymphedema. Avoid very tight or underwire bras when breastfeeding. Too tight bras can cause inflammation in the lactating breast and underwires can do the same. While some would think that our milk ducts are only in the actual mass of the breast, we actually have milk making tissue as far up as our collar bone and armpits, and around the chest wall/breast where one wouldn’t necessarily expect. For those reasons, we want supportive but not tight bras, and NO SPORTS BRAS! My own sister developed an abscess up by her collar bone that required needle drainage from nursing in a sports bra and lifting it over the breast to nurse. Only wear nursing bras and ones that are supportive but not too tight.
Avoid deep or aggressive breast/tissue massage. Don’t touch the breast with more force than you would pet a cat. Using very aggressive breast massage can actually cause tissue trauma and increase the inflammation in the tissue around the milk ducts, further narrowing the milk ducts that are already affected by infections and narrowing. You can see how this will only make the existing issue even worse. I used to try so aggressively to “unclog” the ducts that I thought were backed up that I’d have worse pain from the aggressive massage than I did from the actual mastitis. If you’ve ever experienced mastitis, you know that is an impressive thing!
Avoid nipple shields and breast pumps if possible. Breast pumping and ‘‘pumping to empty’’ perpetuate a cycle of oversupply and is a major risk factor for worsening tissue swelling and inflammation associated with mastitis and backed up areas of the breast. Instead of pumping to relieve congested/inflamed/infected breasts, hand expression can be utilized to provide relief/milk flow. It is important to only hand express what is needed to provide relief, and not to empty the breast. Remember, we do not want to empty the breast beyond what is needed to nourish the infant. In addition, mechanical breast pumps stimulate breast milk production without the ability to empty the breast of milk like an infant can. We do not want to stimulate the breast without also removing all this stimulated milk, this causes a double problem. Pumps are just a poor substitute for a baby. Human babies’ mouths have tissues, tendons, ligaments, muscles and an anatomy that is made to extract milk from a breast. Pumps are plastic or silicone that can only apply suction to a breast. Breast pumps can also cause trauma to the breast if incorrect flange sizes are used, and this trauma can potentiate or worsen inflammation leading to mastitis. Nipple shields can also interfere with optimum expression of milk from the breast and prevent the infant’s mouth and saliva from coming into contact with the mothers skin, preventing the feedback mechanism that is biologically present to aid in balancing the ideal bacterial profile between mom and baby.
Avoid saline soaks, Epsom salt soaks and topical products. Epsom salt haakaa soaks are VERY popular and on many places on the internet. They are NOT recommended. Epsom salt can macerate the nipple, causing tissue trauma and a place for undesirable bacteria to gain entrance where it doesn’t belong. There is some research that topical products like lanolin and possibly nipple butters and creams can potentiate harmful bacteria on the nipple by trapping it in, not allowing oxygen to the nipple, and giving harmful bacteria an entryway to the breast.
Anti-inflammatories and lethicins. Ibuprofen (Motrin) can decrease the inflammation that is amped up in mastitis (please check with your medical care provider before taking any medications or supplements). Soy or Sunflower lecithin can decrease inflammation and possibly make milk flow more easily through smaller ducts (smaller due to inflammation in and around the ducts.) Again, please check with your provider to make sure these medications and supplements are appropriate in your specific situation and with your personal medical history.
Also, it is always helpful to consult with a lactation professional and come up with an individualized plan for mastitis, especially in the case of recurrent mastitis, oversupply, nipple shield use, pumping moms, etc. We can help at After Baby RNs with in person help in the DFW area by IBCLCs and with virtual lactation support for those not local. I hope these new recommendations can save someone’s breastfeeding relationship who might be in a situation similar to the one I was in! Happy National Breastfeeding Month!